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Waste Tire Sub .ey & Inspection Report Inspection Report Number <br /> - ®fT State of California <br /> CIWMB 181( ew 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 Il 1143652 <br /> Part A- Survey_ .-_-__-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- c <br /> � O Inspection Type (Fill one) <br /> Site Suffix: I7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: J �� C�u{� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 4� 0 Ti fe, <br /> Physical Addre� I ` Q ES O <br /> as S- <br /> 5A O Ala <br /> ( CA Inspection Date `7 / 1 z / 1 -0 Time In Time Out <br /> f �J <br /> Business Rep Title woe n 0 AM 4 C 0 AM <br /> n�U tl-(L W a Je r PM ` J ® PM <br /> ------- - - - -- -- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Passenger • Generator • Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> S Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A 1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> Q Q Other: § <br /> Comments I q, �ws�� `rte 1 n ��(� o <br /> 1 t <br /> ��o <br /> viDl�, ��r1s pS - <br /> Inspection Form Included. 7 r - ^ <br /> Comments Included: p+" �� 3N. U-3179- <br /> usiness Rep's Si nature Phone Number Inspe or's Signatur Phone Number <br /> - - - - -- <br /> INSTRUCTIONS ON BACK Correct Incorrect 62081 <br /> - • ' � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy. ® ■ <br />